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            Complaint Form

Your Name:  

Your Contact Information (phone and/or email): 

Enter your preferred contact information for follow-up questioning.

*Date:  
 
Enter date when work was being performed.

*Address, City: 
          
Enter address and location of facility where work is being done.

Company Name:

Enter the name of the company performing work (if known).

Check all that apply:

Pressure Washing   Children Present 

Dry Scraping          Not controlling dust and debris

*Details: 

Enter as much specific details on how the the work is being done and any potential violations.

* Indicates mandatory fields.

To include photos, attach and send a separate email to DHSLeadSafe@wisconsin.gov with the photos. In the Subject line type the address of the property.

 

 

 

 

Home Page - Lead-Safe Wisconsin

Last Revised: December 03, 2010